Standing balance in patients with whiplash-associated neck pain and idiopathic neck pain when compared with asymptomatic participants: A systematic review

Changes in gait performances during walking with head movements in older adults with chronic neck pain

Background

Chronic neck pain (CNP) can lead to altered gait which is worse when combined with head movement. Gait parameters for indicating speed and symmetry have not been thoroughly investigated in older adults with CNP. This study aimed to compare gait performance in term of speed and symmetry in older adults with and without CNP during walking with head movement.

Methods

Fifty young older adults, consisting of 36 healthy controls without neck pain (OLDs) and 14 older adults with CNP, participated in the study. Participants completed the Neck Disability Index and Activities-specific Balance Confidence Scale. The 10-Meter Walk Test (10MWT) was used to assess gait performance. Participants were instructed to walk at preferred speed under three different head movement patterns: no head movement (NM), horizontal head movement (HM), and vertical head movement (VM). The Inertial Measurement Unit was used to capture gait performance, and its software was used to analyze gait variables; gait speed, Locomotor Rehabilitation Index (LRI), gait asymmetry index, Phase Coordination Index (PCI).

Results

The CNP group reported moderate neck pain with mild disability in activities of daily living, and less balance confidence than the OLD group (p < 0.05). The CNP group showed significantly slower gait speed and lower LRI during walking with both the HM and VM (p < 0.05), which corresponded to lower stride length and cadence. The gait asymmetry index in the CNP group was significantly higher than the OLD group during walking with VM (p < 0.05), whereas the PCI was significantly higher than the OLD group during walking with both HM and VM (p < 0.05).

Conclusion

Chronic neck pain affects both speed and symmetry when walking with head movement. Gait parameters in this study could be implemented to identify changes in speed and symmetry of gait in older adults with CNP who have mild disability and high physical functioning.

Balance alterations are associated with neck pain and neck muscle endurance in migraine

BACKGROUND

Migraine patients may present with both cervical and balance dysfunctions. The neck plays an important role in balance by providing substantial proprioceptive input, which is integrated in the central nervous system and influences the balance control systems. Whether balance and neck dysfunctions are associated in patients with migraine is still to be explored.

OBJECTIVES

This study aimed to assess the association between the sensory organization test of balance with neck pain features, cervical strength, endurance, and range of motion in patients with migraine.

METHODS

Sixty-five patients with migraine underwent the sensory organization test assessed with the Equitest-Neurocom® device. Maximum voluntary isometric contraction, cervical flexion and extension range of motion, and cervical flexor and extensor endurance were assessed. In addition, the features of migraine and neck pain were collected. Patients were dichotomized according to cut-off scores of balance performance and the association between outcomes were explored.

RESULTS

Patients with reduced balance performance presented a higher frequency of migraine (p = 0.035), a higher frequency of aura (p = 0.002), greater neck pain intensity (p = 0.013), and decreased endurance of cervical flexors (p = 0.010) and extensors (p < 0.0001). The total balance score was correlated with age (r = -0.33; p = 0.007), migraine frequency (r = -0.29; p = 0.021), neck pain intensity (r = -0.26; p = 0.038), and endurance of the cervical flexors (r = 0.39; p = 0.001) and extensors (r = 0.36; p = 0.001). Migraine frequency, neck pain intensity, and endurance of the cervical flexors can predict 21% of the sensory organization test variability.

CONCLUSION

Neck pain features and endurance of the cervical muscles are related to reduced balance performance in patients with migraine. These results shed light to a better understanding of balance alterations in migraine patients.

Pain-side related difference in cross-sectional area of the longus colli muscle and its relationship with standing balance in persons with non-specific neck pain

BACKGROUND

Longus colli muscle has a significant role in postural control. A reduction of longus colli cross-sectional area (CSA) has been demonstrated in neck pain patients. However, pain-side related difference and its relationship with clinical features and standing balance remain unclear.

OBJECTIVE

To investigate side-to-side difference in the longus colli CSA and to determine the relationships of the CSA with clinical characteristics and standing balance in neck pain patients.

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

Fifty participants with chronic non-specific neck pain (20 unilateral and 30 bilateral) were recruited. CSA of the longus colli muscle was measured using ultrasound imaging. Balance was measured using a force platform during a narrow stance with eyes open, eyes closed, and neck torsion (left and right). Balance outcomes were sway area and displacement in anterior-posterior (AP) and medial-lateral (ML) directions. Clinical characteristics were neck pain intensity, disability, and duration.

RESULTS

The longus colli CSA was reduced on the painful side in patients with unilateral neck pain (p < 0.01). There was a trend towards reduced CSA on the more painful side in those with bilateral neck pain (p = 0.08). The reduced CSA was mostly correlated with the greater AP sway displacement and sway area (r ranged from -0.27 to -0.54, p < 0.05). The longus colli CSA was not correlated with pain intensity, disability, and duration (p > 0.05).

CONCLUSION

The longus colli CSA was reduced on the painful side of neck pain. The reduced CSA was correlated with impaired standing balance, but not with clinical characteristics of neck pain.

Prevalence of Static Balance Impairment and Associated Factors of University Student Smartphone Users with Subclinical Neck Pain: Cross-Sectional Study

The aim of this study was to assess the prevalence of static balance impairment in university student smartphone users with subclinical neck pain and identify the associated risk factors. Because of rapid and widespread smartphones use, and the subsequent effect on neck pain in university students, it is essential to determine the prevalence of balance impairment and associated factors in this population. Simple random sampling was completed among eighty-one participants in this cross-sectional study. A self-reported questionnaire, fitted precisely for smartphone users, was used prior to clinical assessment by the Balance Error Scoring System. Both simple and multiple logistic regressions were used to analyze the prevalence of static balance impairment and associated factors. The prevalence of static balance impairment in university student smartphone users with subclinical neck pain was 74.07% (95% CI: 64.32 to 83.82). The significant risk factors were "daily smartphone use ≥ 4 h'' (AOR: 19.24 (95% CI 4.72 to 78.48) p = 0.000), "≥4 years of smartphone use" (AOR: 5.01 (95% CI 1.12 to 22.38) p = 0.035), and "≥7 neck disability index score'' (AOR: 12.91 (95% CI 2.24 to 74.45) p = 0.004). There was a high prevalence of static balance impairment in university smartphone users with subclinical neck pain. University student smartphone users with subclinical neck pain who met at least one of the risk factors should realize their static balance impairment.

Development and validation of the ND10 to measure neck-related functional disability

Background

Previous neck-specific patient-reported outcome measures (PROMs) have tended to measure both symptoms and disability. This multi-staged study developed and evaluated a neck-specific PROM focusing on functional disability.

Methods

This study integrated findings from systematic reviews on neck-specific outcome measures, patient interviews, qualitative studies on neck disability, and iterative item testing to develop a 10-item measure of neck-related disability (ND10). Content validity was assessed by classifying items using the International Classification of Functioning, Disability and Health (ICF) and perspective linking. Patients (n = 78) with neck pain completed cognitive interviews, exploring items of the Neck Disability Index (NDI) and ND10, and completed structured questions related to literacy and relevance. Test–retest reliability and internal consistency were evaluated using intraclass correlation coefficients, Bland Altman graphs, and Cronbach’s alpha. Concurrent convergent validity was evaluated by comparing the ND10 to the NDI, Single Assessment Numeric Evaluation (SANE), and Disabilities of the Arm, Shoulder and Hand (DASH). Known group validity was determined by comparing ND10 scores from patients, who rated their neck as more or less than 1/2 of “normal” on the SANE, using t-tests.

Results

The ND10 requires respondents to make rational judgements about their neck-related body function and disability. It has high internal consistency (0.94) and re-test reliability (0.87; SEM = 3.2/100; MDC = 7.5); and no re-test bias (mean re-test difference of 0.6). It followed expected correlation patterns, being highly correlated with related multi-item PROMs (r = 0.85–0.91), and moderately correlated to the single-item SANE. More patients agreed that the ND10 was easily readable than did so for the NDI (84% vs 68%; p < 0.05). All the PROMs distinguished the patients who perceived themselves as being abnormal/normal defined by a dichotomized SANE (p < 0.01).

Conclusion

The ND10 is reliable and valid for measuring neck-related functional disability. Longitudinal and cross-cultural translation studies are needed to support future use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05556-7.

Visual, Vestibular, and Proprioceptive Dependency of the Control of Posture in Chronic Neck Pain Patients

Sensory reweighting of postural control was compared in participants with and without neck pain. Center of pressure variables of 60 volunteers, the same in each group, were calculated under four standing conditions: (a) eyes open, neutral head posture; (b) foam interface, eyes open; (c) cervical extension, eyes open; and (d) cervical extension, eyes closed. All center of pressure variables except anterior posterior range/velocity increased significantly in Condition 2 compared with Conditions 1 and 3 (p < .001) and in Condition 4 compared with Conditions 1 and 3. The mediolateral range/velocity and path length in both groups, anterior posterior range in patients, and center of pressure area in the control group were significantly different between Conditions 2 and 4 (p < .001). No overweighting was observed on the vestibular or visual afferents in patients. Compensatory strategies seem to lie within the proprioceptive system.

Comparison of kinematic similarity index during gait between adults with and without nonspecific chronic neck pain

BACKGROUND

Individuals with nonspecific chronic neck pain (NP) walk with a stiffer spine. However, there is a lack of understanding on kinematic similarities on the limbs during gait between individuals with and without NP.

RESEARCH QUESTION

Are there differences in gait parameters and the kinematic similarity index (SI) between individuals with and without NP?

METHODS

Eighteen individuals with NP and 17 controls participated in this study. A three-dimensional motion capture system and two force plates were utilized to measure kinematic changes of the upper and lower limbs during gait. The gait parameters included cadence, speed, stride length, and step width. The SI calculations were compared based on the response vectors from the NP group and the prototype response vectors from the control participants. The SI values at 5% intervals of the entire gait cycle were compared between groups.

RESULTS

Although the gait parameters were not significantly different between groups, the SI values of the control group were significantly higher than the NP group during gait (0.98 ± 0.02 vs. 0.95 ± 0.03), especially at the midstance (10-30 %) and swing (80-90 %) phases. Also, the standard deviation of the SI decreased in the control group when compared to the NP group (0.02 ± 0.01 vs. 0.04 ± 0.02).

SIGNIFICANCE

The SI was a useful measure to differentiate similarities between groups in the gait cycle at specific phases. These results indicated that the NP group demonstrated a greater variation of walking patterns during the midstance and swing phases and displayed altered compensatory gait. Clinicians need to consider the similarities of the kinematic changes for the NP group to aid in detection of limb motion differences and the resulting gait dysfunction.

Investigation of balance performance under different sensory and dual-task conditions in patients with chronic neck pain

BACKGROUND

Most studies suggest that people with chronic neck pain (CNP) have decreased balance abilities. However, balance performance during performing concurrent tasks is not clarified.

OBJECTIVES

To investigate balance performance under different sensory and dual-task conditions in people with and without CNP.

METHOD

Twenty-two women with CNP and twenty-two asymptomatic women were tested using the Biodex Stability System. Overall stability index (OSI), anterior/posterior stability index (APSI), medial/lateral stability index (MLSI) were obtained in two sessions: eyes-open and eyes-closed. Both sessions consisted of four conditions: quiet standing, rotating head, counting backward, standing on foam. Higher index scores mean poorer balance.

DESIGN

Case-Control study.

RESULTS

A mixed factorial ANOVA (2 × 8 design) showed that there was a main effect of CNP on OSI, APSI, and MLSI (p < 0.001), which indicates that CNP causes poor balance. Further, there was an interaction between CNP and test conditions for only OSI (p < 0.05). Simple effects tests showed that patients with CNP had higher OSI in all conditions except standing on foam with eyes-open, and quiet standing and counting backward with eyes-closed (p < 0.05). The largest effect size was obtained during rotating head with eyes-open (η²:0.301), followed by counting backward with eyes-open and quiet standing with eyes-open (η²:0.267 and 0.245). Performing a concurrent task, closing eyes, or standing on foam mostly increased OSI in both groups (p < 0.05).

CONCLUSIONS

Patients with CNP have poorer balance under different sensory and dual-task conditions. Addressing balance assessment while performing concurrent tasks, especially head rotations, may offer new insights into the management of CNP.

Association between musculoskeletal function and postural balance in patients with long-lasting dizziness. A cross-sectional study

BACKGROUND AND PURPOSE

Reduced balance and musculoskeletal pain are frequently reported among patients with long-lasting dizziness. However, the association between musculoskeletal function and postural sway among these patients has not been examined. The objective of this study was to examine if there is an association between aspects of musculoskeletal function and postural balance in patients with long-lasting dizziness.

METHODS

This was a cross-sectional study, using data of 105 outpatients with long-lasting dizziness. Aspects of musculoskeletal function was assessed by examining body flexibility, grip strength, preferred and fast walking speed, in addition to musculoskeletal pain. Musculoskeletal pain was evaluated using the Subjective Health Complaints questionnaire. Postural balance was assessed by path length of postural sway by using a balance platform on both firm and soft surfaces, with eyes open and closed. The association between musculoskeletal function and postural sway was assessed using linear regression analyses.

RESULTS

When adjusting for age and gender we found that on a firm surface, there was an association between increased musculoskeletal pain and increased postural sway measured with eyes open (p = 0.038). In addition, there was an association between decreased body flexibility and decreased postural sway with eyes open (p = 0.025). On a soft surface, decreased fast walking speed was associated with increased postural sway with eyes open (p = 0.027). In addition, decreased grip strength was associated with increased postural sway on a soft surface with eyes closed (p = 0.015).

DISCUSSION

The findings from this study imply that musculoskeletal function may associate with postural sway in patients with long-lasting dizziness, although the associations were weak.

A meta-analysis and systematic review of changes in joint position sense and static standing balance in patients with whiplash-associated disorder

OBJECTIVE

To synthesise and analyse the current evidence regarding changes in joint position sense (JPS) and standing balance in people with whiplash-associated disorder (WAD) taking the presence or absence of dizziness into account.

DATA SOURCES

PubMed, CINAHL Plus, Web of Science, Embase, MEDLINE and APA PsycINFO were searched by two independent reviewers from inception until August 2020 and reference lists of all included studies were also reviewed.

STUDY SELECTION

Only cross-sectional studies that measured JPS and/or standing balance between people with WAD vs. healthy controls (HC) or people with WAD complaining of dizziness (WADD) vs. those not complaining of dizziness (WADND) were selected.

DATA EXTRACTION

Relevant data were extracted using specific checklists and quality assessment was performed using Downs and Black Scale (modified version).

DATA SYNTHESIS

Twenty-six studies were included. For JPS, data were synthesized for absolute error in the primary plane of movement for separate movement directions. For standing balance, data were synthesized for traditional time- and frequency domain sway parameters considering the conditions of eyes open (EO) and eyes closed (EC) separately. For meta-analysis, reduced JPS was observed in people with WAD compared to HC when the head was repositioned to a neutral head position (NHP) from rotation (standardised mean difference [SMD] = 0.43 [95%: 0.24-0.62]) and extension (0.33 [95%CI: 0.08-0.58]) or when the head was moved toward 50° rotation from a NHP (0.50 [0.05-0.96]). Similarly, people with WADD had reduced JPS compared to people with WADND when the head was repositioned to a NHP from rotation (0.52 [0.22-0.82]). Larger sway velocity and amplitude was found in people with WAD compared to HC for both EO (0.62 [0.37-0.88] and 0.78 [0.56-0.99], respectively) and EC (0.69 [0.46-0.91] and 0.80 [0.58-1.02]) conditions.

CONCLUSION

The observed changes of JPS and standing balance confirms deficits in sensorimotor control in people with WAD and especially in those with dizziness.

Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers

Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB). However, the mCTSIB is a standard group of tests relying largely on eyes-open and -closed standing positions with the head in a neutral position, associated with probability of missing postural instabilities associated with head positions off the neutral plane. Postural stability scores are compromised with changes in head positions after concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores than the standardized head neutral position of the mCTSIB in Post-Concussion Syndrome (PCS) subjects but not in normal healthy controls. This phenomenon may serve as a diagnostic biomarker to differentiate PCS subjects from normal ones as well as serving as a measurement with which to quantify function or the success or failure of a treatment. Head positions off the neutral plane provide novel biomarkers that identify and differentiate subjects suffering from PCS from healthy normal subjects.

Joint Assessment of Equilibrium and Neuromotor Function: A Validation Study in Patients with Fibromyalgia

OBJECTIVE

To develop and validate a tool for evaluating balance and neuromotor function in patients with fibromyalgia (FMS).

METHODS

Brainstorming, the nominal group technique, and pilot-testing were used to select a battery of 20 functional balance tests that were included in a screening tool. A total of 108 subjects (62 with fibromyalgia syndrome, 22 aged over 65 years, and 24 healthy subjects) participated in this validation study. Factor validity, internal consistency, the ability to discriminate between patients and healthy subjects, and concurrent validity with the Fibromyalgia Impact Questionnaire (FIQ), the Central Sensitization Inventory (CSI), the 12-Item Short-Form Health Survey (SF-12), and other tools for measuring balance, such as the Dizziness Handicap Inventory (DHI), the Activities-Specific Balance Confidence Scale (ABC-16), the Falls Efficacy Scale-International (FES-I), and posturographic parameters, were evaluated.

RESULTS

The factorial analysis extracted four factors that explained 70% of the variance. The Alpha Cronbach value was 0.928. Concurrent validity of the screening tool with respect to other tools was high, and the receiver operating characteristic (ROC) curve analysis showed an AUC value of 0.932 for discriminating between healthy and FMS subjects. Severe balance disorder related to head movements in FMS patients was found.

CONCLUSION

The 20-item JAEN (Joint Assessment of Equilibrium and Neuro-motor Function) screening tool is a valid and reliable tool for assessing balance in patients with FMS.

Effects of local vibration and cervical stabilization exercises on balance, joint position sense, and isometric muscle performance in young adults: A randomized controlled study

BACKGROUND: Cervical stabilization exercises and local vibration may improve proprioception and balance and prevent musculoskeletal problems. OBJECTIVE: To compare the effects of local vibration and cervical stabilization exercises on balance, cervical joint position sense, and muscle performance in healthy participants. METHODS: Forty-eight healthy male participants without neck pain were included. The participants were randomly divided into three groups: a home exercise program lasting eight weeks to the cervical stabilization group; 60 s of vibration to the neck muscles of the local vibration group and a control group. Balance, joint position sense, and muscle performance were evaluated twice in all subjects, before and after the intervention. RESULTS: Joint position sense error values were decreased in both the local vibration and cervical stabilization groups. Balance was improved (p< 0.001) in the local vibration group while improvement in muscle performance parameters was only seen in the cervical stabilization group (p< 0.05). CONCLUSIONS: The methods used in the present study may be used for improving the proprioceptive and vestibular components of balance in individuals with musculoskeletal problems such as cervical disc herniation, cervical spondylosis, or neck pain. However, given the limitations, much more research is needed to firmly establish these recommendations.

Can a simple clinical test demonstrate head-trunk coordination impairment in neck pain?

BACKGROUND

Sensorimotor impairment in neck pain sufferers is well established. Recent research has identified impairment in head and trunk co-ordination in this population. Presently, no clinically appropriate testing exists to quantify such impairment.

OBJECTIVE

To determine if a simple and clinically relevant test of head-trunk co-ordination can identify dysfunction in neck pain subjects when compared to healthy controls.

STUDY DESIGN

Cross-sectional observational study.

METHODS

Thirty-one neck pain and 29 healthy control subjects were assessed using head- and chest-mounted lasers with a target positioned 90 cm away. Subjects were required to rotate the trunk at least 45° with the head laser to be kept as accurately as possible in the centre of the target while sitting and standing. Maximal deviation of the head to the left and right of the target's centre with each trunk movement was measured.

RESULTS

The neck pain group demonstrated significantly greater head deviation from the centre in all but one test direction (p= <0.03). Head deviation to the same side as trunk rotation was larger in the neck pain group for both sitting and standing (p= <0.01). No significant differences existed between testing in sitting and standing.

CONCLUSION

Differences in trunk-head control exist in persons suffering from neck pain compared to healthy individuals, which can be demonstrated using simple equipment suggesting clinical utility of the measure. Performing the task in standing would seem most suitable as it can avoid influence by reduced thoracic mobility. Further research is required to establish the clinical suitability of this test.

Short-term effects of spinal thrust joint manipulation on postural sway in patients with chronic mechanical neck pain: a randomized controlled trial

PURPOSE

Our aim was to compare the efficacy of spinal manipulation of the upper cervical spine (C1-C2) on postural sway in patients with chronic mechanical neck pain with the application of a combination of cervical (C3-C4), cervicothoracic (C7-T1) and thoracic spine (T5-T6) thrust joint manipulation.

METHODS

One hundred eighty-six (n = 186) individuals with chronic mechanical neck pain were randomised to receive an upper cervical spine manipulation (n = 93) or three different spinal manipulation techniques applied to the cervical spine, cervicothoracic joint and thoracic spine (n = 93). Measures included the assessment of stabilometric parameters using the Medicapteurs S-Plate platform. Secondarily, neck pain was analysed using the Numeric Pain Rating Scale.

RESULTS

We observe a decrease in the length of the centre of pressure path, average speed, medio-lateral and antero-posterior displacement with statistically significant results (p < 0.05) in the upper cervical manipulation group. Both interventions are equally effective in reducing neck pain after fifteen days (p < 0.001).

CONCLUSION

The application of upper cervical thrust joint manipulation is more effective in improving stabilometric parameters in patients with chronic mechanical neck pain. Trial registration: The study was registered in the Australian and New Zealand Clinical Trial Registry (no. ACTRN12619000546156).Implications for rehabilitationPatients who suffer from neck pain exhibit increased postural sway than asymptomatic subjects.Both spinal manipulation treatments applied in this study are equally effective in reducing neck pain.Spinal manipulation treatment on the upper cervical spine improves postural stability parameters.

Hub disruption in patients with chronic neck pain: a graph analytical approach

Chronic pain is known to alter the brain's network dynamics. These dynamics are often demonstrated by identifying alterations in the brain network topology. A common approach used for this purpose is graph theory. To date, little is known on how these potentially altered networks in chronic pain relate to the symptoms reported by these patients. Here, we applied a graph theoretical approach to identify network changes in patients suffering from chronic neck pain, a group that is often neglected in chronic pain research. Participants with chronic traumatic and nontraumatic neck pain were compared to healthy pain-free controls. They showed higher levels of self-reported symptoms of sensitization, higher levels of disability, and impaired sensorimotor control. Furthermore, the brain suffering from chronic neck pain showed altered network properties in the posterior cingulate cortex, amygdala, and pallidum compared with the healthy pain-free brain. These regions have been identified as brain hubs (ie, regions that are responsible for orchestrating communication between other brain regions) and are therefore known to be more vulnerable in brain disorders including chronic pain. We were furthermore able to uncover associations between these altered brain network properties and the symptoms reported by patients. Our findings indicate that chronic neck pain patients reflect brain network alterations and that targeting the brain in patients might be of utmost importance.

Cervical proprioceptive impairment in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) involving the cervical spine can lead to various neurologic defects and impairment of proprioception is just one of them. The aim of this study was the assessment of cervical proprioception and its relation with radiographic, clinical, and functional characteristics of patients with RA. One hundred and six rheumatoid arthritis patients who diagnosed according to the 2010 American College of Rheumatology/European League Against Rheumatism criteria and age, gender, educational status matched one hundred and six healthy volunteers were enrolled in this study. Cervical joint position error test (CJPET) was applied to healthy volunteers and RA patients for cervical proprioception assessment. Fatigue, depression, balance, quality of life and balance scales were administered to all patients. Cervical radiography was used to assess cervical subluxations. Regression analysis was used for grading the factors which had relations with cervical proprioception. Mean age of patients and healthy volunteers was 51 ± 11.1 and 48.9 ± 9.2, respectively. Scores of CJPET were statistically significantly higher in RA group than healthy volunteers (p = 0.001). CJPET scores were negatively correlated with Berg balance scale findings in right rotation, left rotation, flexion and extension (rho = - 0.421,- 0.473,- 0.448,- 0.515). There was weak or not significant correlation between the scores of CJPET and fatigue, depression, and quality of life scales. Scores of CJPET in patients with atlantoaxial subluxations (AAS) were statistically significantly higher than those without AAS (p < 0.05). Regression analysis results showed that the AAS was related to impaired cervical proprioception on right and left rotations. There was no correlation between CJPET scores and functional parameters. Cervical proprioception impaired in RA patients. This impairment was related to the existence of AAS and balance problems.

Associations between brain morphology and motor performance in chronic neck pain: A whole-brain surface-based morphometry approach

Changes in brain morphology are hypothesized to be an underlying process that drive the widespread pain and motor impairment in patients with chronic neck pain. However, no earlier research assessed whole-brain cortical morphology in these patients. This case-control study assesses group-differences in whole-brain morphology between female healthy controls (HC; n = 34), and female patients with chronic idiopathic neck pain (CINP; n = 37) and whiplash-associated disorders (CWAD; n = 39). Additionally, the associations between whole-brain morphology and motor performance including balance, strength, and neuromuscular control were assessed. Cortical volume, thickness, and surface area were derived from high resolution T1-weighted images. T2*-weighted images were obtained to exclude traumatic brain injury. Vertex-wise general-linear-model-analysis revealed cortical thickening in the left precuneus and increased volume in the left superior parietal gyrus of patients with CINP compared to HC, and cortical thickening of the left superior parietal gyrus compared to HC and CWAD. Patients with CWAD showed a smaller cortical volume in the right precentral and superior temporal gyrus compared to HC. ANCOVA-analysis revealed worse neuromuscular control in CWAD compared to HC and CINP, and in CINP compared to HC. Patients with CWAD showed decreased levels of strength and sway area compared to CINP and HC. Partial correlation analysis revealed significant associations between the volume of the precentral gyrus, and neuromuscular control and strength together with an association between the volume of the superior temporal gyrus and strength. Our results emphasize the role of altered gray matter alterations in women with chronic neck pain, and its association with pain and motor impairment.

Gait speed and gait asymmetry in individuals with chronic idiopathic neck pain

BACKGROUND

Recent studies have shown that individuals with chronic idiopathic neck pain (CINP) exhibit altered spatiotemporal gait parameters. Problems arising from the neck joints and related soft tissues, and most mechanical neck pain appear asymmetric. However, whether individuals with CINP have an asymmetric gait has not been clarified.

OBJECTIVES

The aim was to investigate if there was a significant difference in gait speed (GS) and gait asymmetry (GA) between individuals with CINP and healthy controls.

DESIGN

Case-Control Study.

METHOD

Twenty individuals with CINP and 20 healthy controls were included. All participants performed the 10-m walking test in three walking conditions: preferred walking (PW), preferred walking with head rotation and walking at maximum speed (MAXW). The timing gate system and pressure sensitive insoles were used to calculate GS and GA, respectively. GA was calculated using the difference between right and left swing durations.

RESULTS/FINDINGS

Individuals with CINP had slower GS in all walking conditions compared to controls (p < 0.05). In PW and MAXW conditions, gait was found to be asymmetric in individuals with CINP compared to controls (p < 0.05). There was no difference in GA between the walking conditions in either group (p > 0.05).

CONCLUSIONS

Individuals with CINP had a slower and more asymmetrical gait. GA should be evaluated as a part of the routine gait analysis since it has potential to cause asymmetric loading on joints which could cause other musculoskeletal problems in the long-term. Also, future research is needed to clarify the reasons why gait is more asymmetric in individuals with CINP.

A Novel Virtual Reality Technique (Cervigame®) Compared to Conventional Proprioceptive Training to Treat Neck Pain: A Randomized Controlled Trial

Background

Despite the potential benefits of virtual reality technology in physical rehabilitation, only a few studies have evaluated the efficacy of this type of treatment in patients with neck pain.

Objective

The aim of this study was to compare the effects of virtual reality training (VRT) versus conventional proprioceptive training (CPT) in patients with neck pain.

Materials and Methods

Forty four participants with nonspecific chronic neck pain were randomly assigned to VRT or CPT in this assessor-blinded clinical trial. A novel videogame called Cervigame® was designed for VRT. It comprises of 50 stages divided into unidirectional and two-directional stages ordered from easy to hard. CPT consisted of eye-follow, gaze stability, eye-head coordination and position and movement sense training. Both groups completed 8 training sessions over 4 weeks. Visual analogue scale score, neck disability index and Y-balance test results were recorded at baseline, immediately after and 5 weeks post-intervention. Mixed repeated measure ANOVA was used to analyze differences between mean values for each variable at an alpha level of 0.05.

Results

There were significant improvements in all variables in both groups immediately after and 5 weeks after the intervention. Greater improvements were observed in the visual analogue scale and neck disability index scores in VRT group, and the results for all directions in Y-balance test were similar in both groups. No side effects were reported.

Conclusion

Improvements in neck pain and disability were greater in VRT than CPT group. Cervigame® is a potentially practical tool for rehabilitation in patients with neck pain.

Postural control in subclinical neck pain: a comparative study on the effect of pain and measurement procedures

BACKGROUND AND AIMS

This study investigated whether young university students with neck pain (NP) have postural control deficits when compared to sex and age-matched asymptomatic subjects.

METHODS

Centre of pressure (COP) sway area, velocity, anterior-posterior and mediolateral distances were measured in participants with (n=27) and without (n=27) neck pain for different combinations of static standing (narrow stance, tandem stance and single leg stance) and measurement time (90, 60, 30 and 15 s) with eyes closed using a force plate. Additionally, static and dynamic clinical tests of postural control were used.

RESULTS

No significant between group differences were found for the COP measurements (p>0.05). However, individuals with subclinical NP were more likely to fail the 90 s tandem test (p<0.05) in the force plate and univariate comparisons revealed significant between group differences in the tandem and single leg stance clinical test measurements.

CONCLUSIONS

Taken together, the inconsistent results might suggest an emerging postural control deficit in university students with low disability and low intensity chronic idiopathic NP.

The effect of cervical spine subtypes on center of pressure parameters in a large asymptomatic young adult population

BACKGROUND

Recent research highlighted that non-lordotic subtypes are common within an asymptomatic population of young adults. The potential mechanisms responsible for the decreased postural control witnessed in healthy participants exhibiting non-lordotic cervical alignment are unclear.

RESEARCH QUESTION

Therefore, the aim of this study is to compare and contrast asymptomatic radiographically derived sagittal cervical alignment subtypes with Center of Pressure (CoP) parameters.

METHODS

In this cross-sectional study strict asymptomatic inclusion criteria were met by 150 of the original 182 volunteers. All radiographs were assessed using a multi-method subtype system with participants classified into lordotic and non-lordotic groups. Participants performed 90s narrow stance trials with their eyes closed whilst standing on both a firm surface (FS) and compliant surface (CS) (3 trials per surface). CoP parameters were recorded from a force platform sampling at 100 Hz. Nonparametric statistical tests were conducted to assess differences between groups for each surface type and to determine differences in CoP parameters between FS and CS types.

RESULTS

Significant differences were found between groups on both surfaces for the anterior to posterior range (FS: p = 0.013; CS: p = 0.023), total excursion (FS: p = 0.029; CS: p = 0.005) and mean velocity of total excursion (FS: p = 0.032; CS: p = 0.004).

SIGNIFICANCE

Our data suggest that sagittal plane cervical alignment is a measure capable of distinguishing between the postural control of asymptomatic lordotic and non-lordotic young adult participants on both surfaces types. Furthermore, decreased postural control is present in asymptomatic participants across all non-lordotic subtypes and is not isolated exclusively to those with forward head posture. Consequently, future research endeavours should investigate the clinical significance of these non-lordotic findings in relation to both the potential for early cervical osseous degeneration and the transitional stages of non-specific pain sufferers from previously asymptomatic young adults.

Motor impairment in patients with chronic neck pain: does the traumatic event play a significant role? A case-control study

BACKGROUND CONTEXT

Motor impairment is a key sign in patients with traumatic (whiplash-associated disorder [WAD]) and non-traumatic (idiopathic neck pain [INP]) neck pain.

PURPOSE

This study aimed to analyze differences in motor impairment between two patient groups and to assess the association between motor performance and self-reported symptoms.

STUDY DESIGN

This is a case-control study.

PATIENT SAMPLE

A total of 38 patients with chronic INP, 35 patients with chronic WAD, and 30 healthy pain-free controls were included in the study.

OUTCOME MEASURES

Outcome measures used in this study were mobility (°), strength (N), repositioning accuracy (°), endurance (seconds), sway velocity (cm/s), sway area (cm²), and neuromuscular control.

METHODS

Group differences of motor impairment, together with questionnaires to evaluate pain intensity, fear avoidance, pain catastrophizing, symptoms of central sensitization, and disability, were analyzed with analysis of covariance, including age as a covariate.

RESULTS

Motor impairment was observed in both patient groups with a higher degree in patients with chronic WAD. These impairments were moderately linked to self-reported disability and were in most cases associated with pain, fear avoidance, and symptoms of central sensitization (|ρ| ranging from 0.28 to 0.59).

CONCLUSIONS

Motor impairment should be addressed when treating both groups of patients, keeping in mind the association with self-reported pain and disability, fear-avoidance, and central sensitization.

COACH CV: The Seven Clinical Phenotypes of Concussion

Our understanding of the diverse physiological manifestations of concussion is changing rapidly. This has an influence on the clinical assessment of patients who have sustained a concussion. The 2017 Consensus Statement on Concussion in Sport states that numerous post-injury clinical findings, such as cognitive deficits, post-traumatic headaches, dizziness, difficulties with oculomotor function, and depression have all been associated with a poorer prognosis in concussed patients. This demonstrates that there are several potential clinical manifestations after head injury warranting clinical evaluation. We have developed an acronym to guide the office-based assessment of concussed patients to consider each of the potential clinical phenotypes. "COACH CV" prompts the clinician to evaluate for cognitive problems, oculomotor dysfunction, affective disturbances, cervical spine disorders, headaches, and cardiovascular and vestibular anomalies.

Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain

Synopsis There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms. However, there are other possible causes for these symptoms, and secondary adaptive changes should also be considered in differential diagnosis. Understanding the nature of these symptoms and differential diagnosis of their potential origin is important for rehabilitation. In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits. Once adequately assessed, appropriate tailored management should be implemented. Research to further assist differential diagnosis and to understand the most important contributing factors associated with abnormal cervical afferent input and subsequent disturbances to the sensorimotor control system, as well as the most efficacious management of such symptoms and impairments, is important for the future. J Orthop Sports Phys Ther 2017;47(7):492-502. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7052.

Is the clinical cervical extensor endurance test capable of differentiating the local and global muscles?

BACKGROUND CONTEXT

Differential alterations have been reported in the local and global cervical muscles in the presence of chronic neck pain (CNP), including the endurance alterations of these muscles. Identifying the involved muscles is crucial to the assessment and rehabilitation of patients with CNP.

PURPOSE

To assess the relationship between clinical endurance test results, pain and disability indices, and ultrasonographic (US) measurements of the neck extensor muscles; to compare the deep and superficial cervical extensor muscle endurance and size of CNP patients with those of asymptomatic subjects and to compare the relationship between local and global extensor endurance with US measures, pain intensity, and disability.

STUDY DESIGN/SETTING

Cross-sectional correlational analysis with a case-control design.

PATIENT SAMPLE

Thirty patients with CNP and 30 asymptomatic subjects participated in this study.

OUTCOME MEASURES

Endurance, thickness, cross-sectional area, and shape ratio of the cervical extensor muscles (splenius capitis [SpCap], semispinalis capitis [SSCap], semispinalis cervicis [SSCer], and multifidus [MF]); pain intensity measured by the visual analog scale (VAS); neck disability index (NDI); correlation between US measures, pain intensity and NDI and extensor endurance; and correlation of US measures with pain intensity and NDI.

METHODS

The deep and superficial cervical extensor muscle endurance and dimensions were measured via a clinical test and by US, respectively. Participants were asked to hold the neutral chin-tuck position while lying prone. The test would be terminated if the head moved into either flexion or extension, which would yield "global" or "local" extensor muscle endurance, respectively.

RESULTS

The CNP patients showed lower global extensor endurance levels than the control participants (p<.05). The US measures of the deep extensor muscles were also smaller in the CNP group (p<.05). There were no significant correlations between extensor endurance test results and US measures in either group except for the SSCap muscle size with local and total endurance (p=.04 for both) of CNP and control participants, respectively. NDI was correlated with SpCap and SSCer muscle thicknesses in a positive and negative manner, respectively (p=.03 for both). There was also a significant correlation between MF size and VAS (p<.05).

CONCLUSIONS

The findings showed higher levels of global muscle fatigability and smaller size of deep neck extensor muscles in CNP patients. Disability and extensor endurance were found to be associated with extensor muscle size. The results challenge the validity of the clinical extensor muscle endurance test in the differentiation of the deep and superficial extensor muscle endurance and the use of US in the assessment of cervical muscle endurance. Further investigations are needed to judge the superficial and deep muscle endurance in CNP patients.

The efficacy of sagittal cervical spine subtyping: Investigating radiological classification methods within 150 asymptomatic participants

Aims:

The aim of this study is to (1) compare and contrast cervical subtype classification methods within an asymptomatic population, and (2) identify inter-methodological consistencies and describe examples of inconsistencies that have the potential to affect subtype classification and clinical decision-making.

Methods:

A total of 150 asymptomatic 18–30-year-old participants met the strict inclusion criteria. An erect neutral lateral radiograph was obtained using standard procedures. The Centroid, modified Takeshima/Herbst methods and the relative rotation angles in cases of nonagreement were used to determine subtype classifications. Cohen's kappa coefficient (κ) was used to assess the level of agreement between the two methods.

Results:

Nonlordotic classifications represented 66% of the cohort. Subtype classification identified the cohort as, lordosis (51), straight (37), global kyphosis (30), sigmoidal (13), and reverse sigmoidal (RS) (19). Cohen's kappa coefficient indicated that there was only a moderate level of agreement between methods (κ = 0.531). Methodological agreement tended to be higher within the lordotic and global kyphotic subtypes whereas, straight, sigmoidal, and RS subtypes demonstrated less agreement.

Conclusion:

This is the first study of its type to compare and contrast cervical classification methods. Subtypes displaying predominantly extended or flexed segments demonstrated higher levels of agreement. Our findings highlight the need for establishing a standardized multi-method approach to classify sagittal cervical subtypes.

An Attempt of Early Detection of Poor Outcome after Whiplash

The main concern with whiplash is that a large proportion of whiplash patients experience disabling symptoms or whiplash-associated disorders (WAD) for months if not years following the accident. Therefore, identifying early prognostic factors of WAD development is important as WAD have widespread clinical and economic consequences. In order to tackle that question, our study was specifically aimed at combining several methods of investigation in the same WAD patients at the acute stage and 6 months later. Our longitudinal, open, prospective, multi-center study included 38 whiplash patients, and 13 healthy volunteers matched for age, gender, and socio-economic status with the whiplash group. Whiplash patients were evaluated 15-21 days after road accident, and 6 months later. At each appointment, patients underwent a neuropsychological evaluation, a full clinical neurological examination, neurophysiological and postural tests, oto-neurological tests, cervical spine cord magnetic resonance imaging (MRI) with tractography (DTI). At 6 months, whiplash patients were categorized into two subgroups based on the results of the Diagnostic and Statistical Manual of Mental Disorders as having either favorable or unfavorable progression [an unfavorable classification corresponding to the presence of post-concussion symptom (PCS)] and we searched retrospectively for early prognostic factors of WAD predicting the passage to chronicity. We found that patients displaying high level of catastrophizing at the acute stage and/or post-traumatic stress disorder associated with either abnormalities in head or trunk kinematics, abnormal test of the otolithic function and at the Equitest or a combination of these syndromes, turned to chronicity. This study suggests that low-grade whiplash patients should be submitted as early as possible after the trauma to neuropsychological and motor control tests in a specialized consultation. In addition, they should be evaluated by a neuro-otologist for a detailed examination of vestibular functions, which should include cervical vestibular evoked myogenic potential. Then, if diagnosed at risk of WAD, these patients should be subjected to an intensive preventive rehabilitation program, including vestibular rehabilitation if required.

Cervico-ocular Reflex Is Increased in People With Nonspecific Neck Pain

BACKGROUND

Neck pain is a widespread complaint. People experiencing neck pain often present an altered timing in contraction of cervical muscles. This altered afferent information elicits the cervico-ocular reflex (COR), which stabilizes the eye in response to trunk-to-head movements. The vestibulo-ocular reflex (VOR) elicited by the vestibulum is thought to be unaffected by afferent information from the cervical spine.

OBJECTIVE

The aim of the study was to measure the COR and VOR in people with nonspecific neck pain.

DESIGN

This study utilized a cross-sectional design in accordance with the STROBE statement.

METHODS

An infrared eye-tracking device was used to record the COR and the VOR while the participant was sitting on a rotating chair in darkness. Eye velocity was calculated by taking the derivative of the horizontal eye position. Parametric statistics were performed.

RESULTS

The mean COR gain in the control group (n=30) was 0.26 (SD=0.15) compared with 0.38 (SD=0.16) in the nonspecific neck pain group (n=37). Analyses of covariance were performed to analyze differences in COR and VOR gains, with age and sex as covariates. Analyses of covariance showed a significantly increased COR in participants with neck pain. The VOR between the control group, with a mean VOR of 0.67 (SD=0.17), and the nonspecific neck pain group, with a mean VOR of 0.66 (SD=0.22), was not significantly different.

LIMITATIONS

Measuring eye movements while the participant is sitting on a rotating chair in complete darkness is technically complicated.

CONCLUSIONS

This study suggests that people with nonspecific neck pain have an increased COR. The COR is an objective, nonvoluntary eye reflex and an unaltered VOR. This study shows that an increased COR is not restricted to patients with traumatic neck pain.

Neck Flexor and Extensor Muscle Endurance in Subclinical Neck Pain: Intrarater Reliability, Standard Error of Measurement, Minimal Detectable Change, and Comparison With Asymptomatic Participants in a University Student Population

OBJECTIVE

The aims of this study were to assess intrarater reliability and to calculate the standard error of measurement (SEM) and minimal detectable change (MDC) for deep neck flexor and neck extensor muscle endurance tests, and compare the results between individuals with and without subclinical neck pain.

METHODS

Participants were students of the University of Aveiro reporting subclinical neck pain and asymptomatic participants matched for sex and age to the neck pain group. Data on endurance capacity of the deep neck flexors and neck extensors were collected by a blinded assessor using the deep neck flexor endurance test and the extensor endurance test, respectively. Intraclass correlation coefficients (ICCs), SEM, and MDC were calculated for measurements taken within a session by the same assessor. Differences between groups for endurance capacity were investigated using a Mann-Whitney U test.

RESULTS

The deep neck flexor endurance test (ICC = 0.71; SEM = 6.91 seconds; MDC = 19.15 seconds) and neck extensor endurance test (ICC = 0.73; SEM = 9.84 minutes; MDC = 2.34 minutes) are reliable. No significant differences were found between participants with and without neck pain for both tests of muscle endurance (P > .05).

CONCLUSION

The endurance capacity of the deep neck flexors and neck extensors can be reliably measured in participants with subclinical neck pain. However, the wide SEM and MDC might limit the sensitivity of these tests.

Chiropractic Management of Musculoskeletal Symptoms in a 14-Year-Old Hockey Player With Postconcussion Symptoms: A Case Report

OBJECTIVE

The purpose of this study is to describe the chiropractic management of a student athlete with postconcussion syndrome.

CLINICAL FEATURES

A 14-year-old male hockey player presented to a chiropractic clinic with postconcussion symptoms 13 days after his initial injury. He experienced an occipital headache with a pain rating of 8/10, upset stomach, blurry vision, nausea, dizziness, balance problems, a "foggy feeling," difficulty with concentration, difficulty with memory, fatigue, confusion, drowsiness, and irritability. Prior to seeing the doctor of chiropractic, the patient was monitored by a medical doctor, and the care he had been receiving was in accordance with current concussion guidelines. At the time of presentation to the chiropractic clinic, he had failed to progress toward return to play, and his computerized neurocognitive testing scores had not improved.

INTERVENTION AND OUTCOME

Chiropractic manipulative therapy, myofascial release, instrument-assisted soft tissue technique, and therapeutic exercises were provided over 5 treatments spanning a 20-day period. The patient followed up each treatment with ImPACT testing. At the conclusion of the treatments, the patient's computerized neurocognitive testing scores had improved, and the patient was returned to play.

CONCLUSION

This case demonstrates the improvement of postconcussion syndrome in a 14-year-old male hockey player under chiropractic management.

Controlling Posture and Vergence Eye Movements in Quiet Stance: Effects of Thin Plantar Inserts

The purpose of this study was to assess properties of vergence and saccade eye movements as well as posture in quiet stance, and the effects of thin plantar inserts upon postural and oculomotor control. The performances of 36 young healthy subjects were recorded by a force platform and an eye tracker in three testing conditions: without plantar stimulation, with a 3 millimetre-thick plantar insert, either a Medial or a Lateral Arch Support (MAS/LAS). The results showed a decrease of the Surface and Variance of Speed and a more posterior position of the CoP with either stimulation compared with the control condition. The fractal analysis showed a decrease with MAS. Wavelet analysis in the time-frequency domain revealed an increase in the Cancelling Time of the low frequency band with MAS. These results suggest a better stability for a lower energy cost. Concerning eye movements, the inserts influenced only vergence (not saccades): MAS caused an increase of the phasic amplitude of divergence, and conversely a decrease of the tonic amplitude. In contrast, LAS caused an increase of the tonic amplitude of convergence. Thus, MAS renders divergence less visually driven, while LAS renders convergence more visually driven. We conclude that the CNS uses the podal signal for both postural and vergence control via specific mechanisms. Plantar inserts have an influence upon posture and vergence movements in a different way according to the part of the foot sole being stimulated. These results can be useful to clinicians interested in foot or eye.

The role of the cervical spine in post-concussion syndrome

While much is known regarding the pathophysiology surrounding concussion injuries in the acute phase, there is little evidence to support many of the theorized etiologies to post-concussion syndrome (PCS); the chronic phase of concussion occurring in ∼ 10-15% of concussed patients. This paper reviews the existing literature surrounding the numerous proposed theories of PCS and introduces another potential, and very treatable, cause of this chronic condition; cervical spine dysfunction due to concomitant whiplash-type injury. We also discuss a short case-series of five patients with diagnosed PCS having very favorable outcomes following various treatment and rehabilitative techniques aimed at restoring cervical spine function.

Neck muscle vibration can improve sensorimotor function in patients with neck pain

BACKGROUND CONTEXT

People with neck pain display a diminished joint position sense and disturbed postural control, which is thought to be a result of impaired somatosensory afferent activity and/or integration. Afferent processing can be artificially manipulated by vibration and was shown to reduce motor performance in healthy subjects. However, the effect of vibration on sensorimotor function in neck pain patients is scarcely investigated.

PURPOSE

To assess the effect of neck muscle vibration on joint position sense and postural control in neck pain subjects and healthy controls.

STUDY DESIGN

Case control study.

PATIENT SAMPLE

Thirteen neck pain patients and 10 healthy controls participated in the present study.

OUTCOME MEASUREMENTS

Cervical joint position sense and dynamic and static postural stability.

METHODS

Short-term, targeted neck muscle vibration with 100 Hz was applied after baseline measurement.

RESULTS

Vibration had opposite effects in patients and healthy subjects. Patients showed improved joint position sense (p<.01) and reduced dynamic postural sway (p<.05) after vibration, whereas vibration resulted in reduced joint position sense acuity (p<.05) and a nonsignificant increase in postural sway in healthy controls.

CONCLUSIONS

This is the first study showing an improved motor performance after neck muscle vibration in patients with neck pain. Thus, vibration may be used to counteract sensorimotor impairment of the cervical spine. Potential underlying mechanisms are discussed.

Efficacy of a modern neuroscience approach versus usual care evidence-based physiotherapy on pain, disability and brain characteristics in chronic spinal pain patients: protocol of a randomized clinical trial

Background

Among the multiple conservative modalities, physiotherapy is a commonly utilized treatment modality in managing chronic non-specific spinal pain. Despite the scientific progresses with regard to pain and motor control neuroscience, treatment of chronic spinal pain (CSP) often tends to stick to a peripheral biomechanical model, without targeting brain mechanisms. With a view to enhance clinical efficacy of existing physiotherapeutic treatments for CSP, the development of clinical strategies targeted at ‘training the brain’ is to be pursued. Promising proof-of-principle results have been reported for the effectiveness of a modern neuroscience approach to CSP when compared to usual care, but confirmation is required in a larger, multi-center trial with appropriate evidence-based control intervention and long-term follow-up.

The aim of this study is to assess the effectiveness of a modern neuroscience approach, compared to usual care evidence-based physiotherapy, for reducing pain and improving functioning in patients with CSP. A secondary objective entails examining the effectiveness of the modern neuroscience approach versus usual care physiotherapy for normalizing brain gray matter in patients with CSP.

Methods/Design

The study is a multi-center, triple-blind, two-arm (1:1) randomized clinical trial with 1-year follow-up. 120 CSP patients will be randomly allocated to either the experimental (receiving pain neuroscience education followed by cognition-targeted motor control training) or the control group (receiving usual care physiotherapy), each comprising of 3 months treatment. The main outcome measures are pain (including symptoms and indices of central sensitization) and self-reported disability. Secondary outcome measures include brain gray matter structure, motor control, muscle properties, and psychosocial correlates. Clinical assessment and brain imaging will be performed at baseline, post-treatment and at 1-year follow-up. Web-based questionnaires will be completed at baseline, after the first 3 treatment sessions, post-treatment, and at 6 and 12-months follow-up.

Discussion

Findings may provide empirical evidence on: (1) the effectiveness of a modern neuroscience approach to CSP for reducing pain and improving functioning, (2) the effectiveness of a modern neuroscience approach for normalizing brain gray matter in CSP patients, and (3) factors associated with therapy success. Hence, this trial might contribute towards refining guidelines for good clinical practice and might be used as a basis for health authorities’ recommendations.

Trial registration

ClinicalTrials.gov Identifier: NCT02098005.

The effects of head movement and walking speed on gait parameters in patients with chronic neck pain

It has been documented that neck pain can influence sensorimotor function. However, little is known about the effects of head movement and walking speed on gait characteristics in patients with neck pain. The aim of this study was to determine gait characteristics of patients with neck pain during walking with different head movements and gait speeds as compared to a control group without neck pain. Twenty women aged between 18 and 59 years with chronic neck pain (>3 months) and 20 healthy controls of similar age, weight and height were recruited into the study. Participants with neck pain completed the Neck Disability Index and Visual Analogue Pain Scale. The experiment consisted of two walking sessions. The first session included walking with head straight, head up-down, and head turns from side to side. The second session included walking at comfortable and maximum speeds. Each trial was performed twice. Gait parameters measured using GAITRite walkway system were step length, stride length, step time, stride time, step width, cadence and gait speed. Patients with chronic neck pain demonstrated a narrower step width, a shorter step length and a slower gait speed during walking with the head movements and at maximum speed compared to the control group (all p < 0.05). Maximum gait speed was moderately correlated with pain intensity and disability (p < 0.01). The results suggest that patients with chronic neck pain have gait disturbances. This supports the notion that assessment of gait should be addressed in patients with persistent neck pain.

Use of outcome measures in managing neck pain: an international multidisciplinary survey

Purpose:

To determine the outcome measures practice patterns in the neck pain management of various health disciplines.

Methods:

A survey of 381 clinicians treating patients with neck pain was conducted.

Results:

Respondents were more commonly male (54%) and either chiropractors (44%) or physiotherapists (32%). The survey was international (24 countries with Canada having the largest response (44%)). The most common assessment was a single-item pain assessment (numeric or visual analog) used by 75% of respondents. Respondents sometimes or routinely used the Neck Disability Index (49%), the Patient Specific Functional Scale (28%), and the Disabilities of the Arm, Shoulder and Hand (32%). Work status was recorded in terms of time lost by more than 50% of respondents, but standardized measures of work limitations or functional capacity testing were rarely used. The majority of respondents never used fear of movement, psychological distress, quality of life, participation measures, or global ratings of change (< 10% routinely use). Use of impairment measurers was prevalent, but the type selected was variable. Quantitative sensory testing was used sometimes or routinely by 53% of respondents, whereas 26% never used it. Ratings of segmental joint mobility were commonly used to assess motion (44% routinely use), whereas 66% of respondents never used inclinometry. Neck muscle strength, postural alignment and upper extremity coordination were assessed sometimes or routinely by a majority of respondents (>56%). With the exception of numeric pain ratings and verbal reporting of work status, all outcomes measures were less frequently used by physicians. Years of practice did not affect practice patterns, but reimbursement did affect selection of some outcome measures.

Conclusions:

Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggessts overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement in practice. International consensus and better clinical measurement evidence are needed to support this.